Discussion
The results suggest that coercion is frequently applied in ambulance settings. This matches the findings of a Polish study, where 75 % of paramedics had applied coercion in the form of restraint (10). Patients may well feel the negative consequences of coercion more acutely than the healthcare personnel (11). Although coercion is applied in order to reduce the risk of injury to patients and staff (9, 11), earlier research has shown that there is no rise in injuries when the rate of coercion falls (12). However, there is no research available that covers a prehospital setting and that discusses traffic safety issues and other prehospital circumstances. Our findings show that ambulance personnel are at risk when travelling in an ambulance without a fastened seatbelt because they consider this to be necessary to keep the patient safe. Considering the obligation to ensure safety in the workplace, it is troubling that patients and personnel routinely travel in the patient compartment of an ambulance without a fastened seatbelt (13). Moreover, patients and staff, like other occupants of motorised vehicles, are obliged to wear a seatbelt while travelling in road traffic (14). Wearing a seatbelt reduces the risk of being killed or injured in a road traffic accident by up to 60 % (15).
It is the coordinator at the Emergency Medical Communication Centre (AMK) who allocates ambulance personnel to callouts requested by a third party. According to Norwegian legislation on the rights of patients and service users, healthcare personnel who provide health care, are personally responsible for making healthcare decisions when patients refuse treatment (3). However, when the callout has been requested by a third party and the ambulance personnel have no access to the patient's medical records or any other documentation, we have found from experience that ambulance personnel often do not have the information they need about future plans for healthcare provision to be able to determine whether coercion may be warranted.
This study was conducted on a non-random sample of ambulance personnel within a limited geographic area. The findings cannot be generalised because the response rate is low. Ambulance personnel who responded to the same callout may well have reported the same incident, which may have caused the rate of coercion to be over-estimated. Even if the exact rate of coercion applied within the ambulance service is difficult to quantify, the study verifies that coercion does occur. Assessing whether this type of coercion is warranted under current legislation requires discretion and expert knowledge on the many relevant laws beyond the scope of healthcare legislation. There is a need to review our interpretation of the complex legislation, and to consider the equipment available in our ambulances as well as the structural framework, so that patients who refuse health care can be transported in a manner that is safe for patients as well as ambulance service personnel.